Analysis General Remarks In conforming to the design parameters set by the CCG, the Fraser River Port Authority maintains outer and inner dredged channels to accommodate vessels with maximum draughts of 10.7m and 11.5m, to widths of 200to 250m, and 130to 170m, respectively. However, the actual widths of the marked buoyed channel extend beyond these limits to between 250and 310m, as is the case between buoys S8andS2. This difference between the dredged width and buoyed channel width is known to the river pilots. It is not common knowledge and is not mentioned either in the Sailing Directions- British Columbia Coast (South Portion), or on the CHSchart for the Fraser River. This deprives masters and officers of deep-sea vessels and coast pilots of the knowledge of these restrictions between available and navigable channel widths. Distribution of Information on Dredged Channels Knowledge of the latest information on the surveys of the dredged channels and areas of silting is distributed to the river pilots whenever possible within 36hours of the survey. However, the charts depicting this information are not distributed to others such as coast pilots, nor is the information included in the Master Pilot Exchange Card for the ship's crew. In the case of the CielodelCanada, neither the master nor the coast pilot were informed of the dredged depth at the section of the river where the coast pilot assumed the conduct of the vessel. Bridge Resource Management (BRM) BRM is the management of human and technical resources in an operational marine environment and is not limited to passage planning. The success of a bridge team depends on the familiarity of the team with the operation of the navigational aids and the use of good human resource management. Masters and crews are often unaware of the local conditions, and pilots are often unaware of the manoeuvring characteristics of the vessel. Therefore, comprehensive briefings are essential so that both the master, having responsibility of the vessel, and the pilot, having responsibility for the conduct of the vessel, will be aware of all relevant factors that might affect the safe navigation of the vessel. It is customary for the river pilot to present the master with a copy of the Master Pilot Exchange Card, which outlines basic information on the channel width, tidal/current information for the passage, and tug fastening positions. See AppendixA for an example of the card. The master of the CielodelCanada was not presented with the card; however, it was reported that the river pilot discussed some of the contents of the card with the master. The vessel ran aground in a position inside the marked buoyed channel between buoys S2and S0 (as shown on CHS chart No.3490, see Figure1), an area where a bar had been reported to be extending into the dredged channel for the past three years. The river soundings dated 17September2003, which were available to the river pilot, gave a depth of 6.3m at chart datum where the vessel ran aground. The tidal assist for that time was 3.5m, giving an available depth of water of 9.8m. This depth, however, falls short of 10.25m, the maximum draft of the CielodelCanada. The discussion of this information at the onset of the voyage through proper BRM procedures would have provided the coast pilot and bridge team with appropriate information necessary to assess risk and would have provided an opportunity to initiate measures to ensure that the vessel stayed in deeper water until clear of the estuary. The departure of the river pilot resulted in the reduction of the bridge team, which further inhibited effectiveBRM. The officer of the watch, who had been monitoring the transit, accompanied the river pilot to the ladder. The master became engaged on the bridge wing in the transfer of the pilot to the pilot boat. This reduced the previous wheelhouse complement from five to two (the pilot and the helmsman) during a critical point in transit. Pilot Handover Location and Safety Although the charted position for the exchange of pilots is approximately 1.8miles southwest of Sand Heads lighthouse, it is an area where traffic may be encountered and that is open to the effects of inclement weather. It had, therefore, become customary during times of heavy traffic and/or bad weather for the handover to take place within the river, close to the mouth of the river entrance. However, this practice had apparently become the norm, and river pilots hand over the conduct of the vessel to coast pilots prematurely, even when it is not warranted by the prevailing conditions. The grounding took place within the designated compulsory pilotage area for the river pilot. In this instance, the river pilot did not provide the current and channel information, nor did the coast pilot request the information during the pilot exchange. The estuary at the mouth of the river is located at a critical stage of transit for all deep draught vessels, especially outbound vessels. Vessels are required to proceed at reduced speed during pilot transfers. Given that an early transfer of pilots may be appropriate under extenuating circumstances, it is crucial that the proper exchange of information takes place between pilots and the bridge teams. This information includes weather, current, and channel depth and width information. Furthermore, a master of a ship transiting a compulsory pilotage area in Canada expects the pilot to be licensed and to have the necessary skills to conduct the vessel in that area. A pilot who is not licensed to take conduct of the vessel in a particular area should make this information known to the master, who can make informed decisions on how best to conduct the voyage. Action Taken by the Canadian Hydrographic Service (CHS) The CHS Pacific Region issued a Notice to Mariners, outlining the following: buoys do not indicate the width of the dredged channel; due to rapid silting/scouring and/or dredging, charts may not show the latest condition. buoys do not indicate the width of the dredged channel; due to rapid silting/scouring and/or dredging, charts may not show the latest condition. Joint Stakeholder Initiatives A meeting between BCCP, FRPA and PPA was held to review the pilot changeover practices at Sand Heads, and the following recommendations were made: The present channel parameters are to be published and copies given to all British Columbia coast pilots. The FRPA shall be requested to e-mail updated soundings to the PPA whenever they become available. Vessels restricted due to tidal conditions and/or deep draught are requested not to conduct a pilot change before the BCCP/FRPA boundary between buoys S0 and S1. Due to an increase in traffic density on the river, it should also be noted that river transits may take longer than they did in the past. If the coast pilot is present on the bridge at the time of sailing, he/she should be included in the Bridge Resource Management (BRM) discussion with the master. The Canadian Coast Guard sounding site Avadepth has been installed on the BCCP Web site and is accessible by all BCCP pilots. Proposed New Practice for the Fraser River Port In order to increase safety in the harbour, the FRPA is revising its Practices and Procedures and has proposed the following: 8) Vessels Constrained by their Draught The Fraser River Port Authority maintains a deep-sea shipping channel with an inner "corridor" or channel, approximately 130metres wide, that is designed to accommodate ships with a draught of 11.5metres. That inner channel is, in most cases, the only portion of the shipping channel within which deep-draught ships can navigate. In order to increase safety in the harbour, the Fraser River Port Authority intends to revise its Practices and Procedures, pursuant to Section56 of the Canada Marine Act and Rule 1(b) of the Collision Regulations under the Canada Shipping Act. The proposed revision, which is intended to raise mariners' awareness of the special conditions faced by deep-draught vessels in the harbour, will take the form of the following addition to PracticeII- NAVIGATION, effective May1,2004: 8) Vessels Constrained by their Draught At the time of transiting the Fraser River deep-sea shipping channel, or portion thereof, all vessels constrained by their draught, as defined under Rule3(h) of the Collision Regulations under the Canada Shipping Act, and whose voyage has been set up for the inner shipping channel by the Fraser River Pilot's Association, may exhibit in addition to the lights prescribed for power-driven vessels of its characteristics, where they can be best seen, three(3) all-round red lights in a vertical line at night or a cylinder during the day. Rule 3(h) of the Collision Regulations states: "The term 'vessel constrained by her draught' means a power-driven vessel that, because of the vessel's draught in relation to the available depth and width of navigable water, is severely restricted in the vessel's ability to deviate from the course the vessel is following." Furthermore, the Fraser River Port Authority intends to pursue having the Canadian Modification to Rule28 (b) of the Collision Regulations removed: "Notwithstanding paragraph (a), in the Canadian waters of a roadstead, harbour, river, lake or inland waterway, no vessel shall exhibit three all-round red lights in a vertical line or a cylinder." Transport Canada Initiatives With respect to the proposed removal of the Canadian Modification of Rule28(b) of the Collision Regulations concerning vessels constrained by their draught, the Fraser River Port Authority presented this proposal to the CMAC [Canadian Marine Advisory Council] Standing Committee on Navigation and Operations at the May2004 session. There were no concerns expressed about the action being taken by the Fraser River Port to allow vessels to exhibit the 'constrained by their draught' lights and shape. However, the Committee was undecided on whether the Canadian Modification should be removed or not for the Collision Regulations. Some participants supported the proposal, while others felt the prohibition should be removed only on a case-by-case basis. Examples of the need to remove it to address other problem areas or situations were not forthcoming, and the impact of removing this long standing Canadian Modification was uncertain. The Canadian Modifications have, therefore, been retained. The Fraser River pilot handed over conduct of the vessel to the coast pilot and departed the vessel before the commencement of Pilotage Area2 and without ensuring that the bridge navigation team and the coast pilot were aware of existing channel depths. The coast pilot in charge of the vessel's conduct was not aware of the restrictions in channel widths, nor the latest channel depth soundings before assuming the conduct of the vessel. Key members of the bridge team became involved in the pilot transfer, leaving the conduct of the vessel to the coast pilot who did not respond to the vessel's swinging to port quickly enough to prevent the grounding. Ineffective Bridge Resource Management and briefings between the river pilot, the coast pilot and the master and crew prior to and during transit were relevant factors in the grounding.Findings as to Causes and Contributing Factors The Fraser River pilot handed over conduct of the vessel to the coast pilot and departed the vessel before the commencement of Pilotage Area2 and without ensuring that the bridge navigation team and the coast pilot were aware of existing channel depths. The coast pilot in charge of the vessel's conduct was not aware of the restrictions in channel widths, nor the latest channel depth soundings before assuming the conduct of the vessel. Key members of the bridge team became involved in the pilot transfer, leaving the conduct of the vessel to the coast pilot who did not respond to the vessel's swinging to port quickly enough to prevent the grounding. Ineffective Bridge Resource Management and briefings between the river pilot, the coast pilot and the master and crew prior to and during transit were relevant factors in the grounding. Vessels are placed at risk by the practice of Fraser River pilots handing over conduct of the vessels to coast pilots before they reach the area for which the coast pilot is licensed. The updated channel information in the Fraser River is not disseminated to coast pilots, and the incomplete exchange of information between river pilots and coast pilots during the handover compromises the safe navigation of the vessels. Neither the Sailing Directions- British Columbia Coast (South Portion), nor the Canadian Hydrographic Service chart No.3490 (Fraser River) advise the mariner of the difference between the dredged deep channel and the actual buoyed channel widths in the Fraser River.Findings as to Risk Vessels are placed at risk by the practice of Fraser River pilots handing over conduct of the vessels to coast pilots before they reach the area for which the coast pilot is licensed. The updated channel information in the Fraser River is not disseminated to coast pilots, and the incomplete exchange of information between river pilots and coast pilots during the handover compromises the safe navigation of the vessels. Neither the Sailing Directions- British Columbia Coast (South Portion), nor the Canadian Hydrographic Service chart No.3490 (Fraser River) advise the mariner of the difference between the dredged deep channel and the actual buoyed channel widths in the Fraser River. Following the occurrence, the Board expressed concern about navigational issues with stakeholders, including the Canadian Hydrographic Service (CHS) Pacific Region, the Pacific Pilotage Authority (PPA), the British Columbia Coast Pilots Ltd. (BCCP) and the Fraser River Port Authority (FRPA). The concerns included the following: a lack of information regarding channel widths on the chart and in the Sailing Directions- British Columbia Coast (South Portion); information on the latest channel depth is not disseminated to affected stakeholders, and pilot changeover practice. In response, the safety actions outlined below have been initiated by stakeholders.Safety Action Following the occurrence, the Board expressed concern about navigational issues with stakeholders, including the Canadian Hydrographic Service (CHS) Pacific Region, the Pacific Pilotage Authority (PPA), the British Columbia Coast Pilots Ltd. (BCCP) and the Fraser River Port Authority (FRPA). The concerns included the following: a lack of information regarding channel widths on the chart and in the Sailing Directions- British Columbia Coast (South Portion); information on the latest channel depth is not disseminated to affected stakeholders, and pilot changeover practice. In response, the safety actions outlined below have been initiated by stakeholders.